Examination of balance
PTP 565
Quote of the day
The greatest crime is not
developing your own potential.
When you do what you do best,
you are helping others.
Roger Williams
Objectives
• Define balance terminology
• Recognize the use of the ICF Model in balance
examination
• Correctly select and complete a balance
examination using objective measures (SLS,
Romberg/Tandem Romberg, Functional Reach,
Berg, Tinetti, CTSIB, and ABC)
• Recognize normal versus abnormal results of
balance testing (including fall risk)
• Document results of balance testing
Assessing a patient with balance
dysfunction can be
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Complicated
Confusing
Discouraging
Challenging
Rewarding
What types of patients have the
potential for balance impairment?
Definitions
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Postural control
Balance
Center of gravity
Base of support
Postural orientation
Limits of stability
Anticipatory postural responses
Reactionary postural responses
Sensory interaction/orientation
Fundamental Exam
• Examination
– Taking a history
– Systems review
– Tests and Measures
• Body structure and function
• Activity
• Participation
Taking a History
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Chief complaint
Medical history
Recent history of falls/close falls
Medications
Confidence level (participation level)
Systems Review
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Cardiovascular
Integumentary
Neuromuscular
Musculoskeletal
ICF Model
Body Functions and Structure
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ROM
Ms. Strength
Ms. Tone
Coordination
Cognition
Posture
Pain
Body Functions and Structure
• Sensory Systems (cont)
– Somatosensory
• Light touch
• Proprioception/Vibration
• Pain
– Vision
– Vestibular
• Perception
Body Functions and Structure
• Sensory Strategies
– Why is sensory interaction important?
– How do we test sensory interaction in the lab?
– How is sensory interaction testing different then
sensory testing?
• Sensory Systems used to hold balance
– Vision
– Vestibular
– Somatosensory
Body Functions and Structure
• Motor Strategies
– Ankle
– Hip
– Stepping
Motor Strategies: Ankle
• Control of postural sway from ankles and feet
• Head and hips travel in the same direction at
the same time with the body moving as a unit
over the feet
• When it is appropriate to use an ankle
strategy?
– Firm surface
– Foot well supported
– Slow moving with minimal displacement
Motor Strategies: Hip
• Control of postural sway from pelvis and trunk
• Head and hips travel in opposite directions
• When is it appropriate to use a hip strategy?
– Foot not completely supported
– Quick and large displacements
Motor Strategies: Stepping
• Steps with the feet to establish a new base of
support when the center of gravity has
exceeded the original base of support
• When is it appropriate to use a stepping
strategy?
– When the other strategies are not sufficient
enough to maintain equilibrium
Body Functions and Structure
• Modified CTSIB
• Single Leg Stance
• Romberg/Sharpened Romberg
Clinical Test for Sensory Interaction in
Balance
• Clinical version of the Sensory Organization
Test that does not require computerized force
plate
• Designed to assess the patient’s ability to
select and combine sensory information in
different environments
• Does not measure the integrity of the three
sensory systems
Sensory Weighting
Firm Surface
•70% somatosensory
•20% vestibular
•10% vision
Unstable Surface
•10% somatosensory
•60% vestibular
•30% vision
Peterka et al, 2004
Clinical Test for Sensory Interaction in
Balance
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Condition 1:
Condition 2:
Condition 3:
Condition 4:
Condition 5:
Condition 6:
Firm surface, eyes open
Firm surface, eyes closed
Firm surface, dome
Foam surface, eyes open
Foam surface, eyes closed
Foam surface, dome
Single Leg Stance
• Person stands with knee flexed 90° (legs
should not be touching each other)
• Arms crossed around shoulders
• Norms
• Document
– Number of attempts
– Time
– Visual observation during trial
Romberg/Tandem Romberg
• Person stands with feet together (Romberg) and eyes
open
• Repeat the test with eyes closed
• Person stands with one foot directly in front of the
other (Tandem Romberg)
• Normal is the ability to hold the test position for 30
seconds
• Document
– Number of attempts
– Time
– Visual observation during trial
Activity and Participation
Activity Balance Measures
• Berg
• Tinetti
• Functional Reach
Participation Balance Measures
• Activities Based Confidence
Scale
Berg
• 14 test items intended to assess a person's
ability to perform common ADLs safely
• Items are scored from 0 to 4, maximum score
is 56
• Scores < 36 indicate a fall risk close to 100%
Tinetti
• Consists of 2 subscales to screen for balance
and mobility skills in older adults and
determine likelihood of falls
– Balance
– Gait
• Score 19-24 are at moderate risk of falls
• Score <19 are considered high risk for falls
Functional Reach
• Define maximum distance one can reach forward
beyond arm’s length while maintaining fixed base
of support in standing
• Examines limits of stability in forward direction
• Person stands near wall with feet parallel, raises
arm nearest wall to 90° of shoulder flexion,
makes a fist and leans as far forward as possible
• < 6 inches predicative of increased risk of falls
Activities Based Confidence Scale
• 16 item questionnaire that is a measure of
balance self-efficacy in which subjects rate
their confidence performing a variety of in
home and community based functional
activities such as walking in a variety of
environments, reaching, picking things up
from the floor.
• Scores range from 0-100 where higher scores
indicate greater balance confidence
Review
• Examination of a patient with balance disorder can
happen at the level of Body Structure/Function,
Activity, and Participation
• Numerous objective tools to use to examine balance
• No single test of balance is available that covers the
multiple dimensions of balance
• Need to select a test that sufficiently challenges the
patient being tested
• SAFETY
– Gait belt
– Closely guarded
Lab
• Video clips of balance examination
• Paper patient cases
– Select the correct test
– Practice performing and documenting balance
examination